Appropriate Opioid Prescribing for Acute Pain after Surgery

Richard J. Barth Jr.Professor of Surgery

Chief, Section of General SurgeryDartmouth Hitchcock Medical Center

American Urologic AssociationQuality Summit

December 8, 2018

The Opioid Epidemic: Introduction

Prescription opioid deaths quadrupled 2000-2017.

Opioid overdoses now leading cause of injury related deaths:

42,000 opioid overdose deaths in US 2016

37,000 motor vehicle crash deaths in US 2016

Opioid prescribing has also quadrupled in the past 15 years and is highly prevalent:

82.5 prescriptions per 100 persons per yearDart R. NEJM 2015; 372: 241MMWR 2018 67: 349-58https://crashstats.nhtsa.dot.gov

Link between increased opioid prescribing and increasing opioid overdose deaths…

• FDA: “The crisis will continue unabated unless clinicians stop prescribing opioids far in excess of clinical need.”

Califf R. NEJM 2016; 374: 1480

Surgeons play an important role in the opioid epidemic

Surgeons commonly prescribe opioids after surgery

Prescribing opioids for our patients has risks for them:

• 5-10% of opioid naïve patients become chronic users after prescribed opioids for surgery.

The pills our patients don’t use can be used by others:

• Diversion: 71% of users get drugs by diversion.

5-10% of opioid naïve patients become chronic users after prescribed opioids for surgery

Study N % chronic users Definition

Alam 2012 390,000 7 On opioids 1 year after surgery

Deyo 2016 536,000 5 >5 refills subsequent year

Johnson 2016 59,000 13 New script 90-180 days after surgery

Brummet 2017 55,000 6 New script 90-180 days after surgery

Lee 2017 68,000 10 New script 90-180 days After surgery

Jiang 2017 79,000 9 On opioids 90 days after surgery

Shah 2017 1,295,000 5 On opioids 1 year after surgery

Initial prescription size matters…

A. Shah MMWR 2017; 66: 265-9

Studied 1,250,000 opioid naïve patients

• 1 day prescription: 6% chance on opioids @ 1 year

• 8 + day prescription: 13% chance on opioids @ 1 year

PREVENT long term use by right-sizing initial opioid prescription

Literature Review: 2015

Few studies exist that address optimal post-operative opioid prescriptions

• Urologic, oral, hand, and upper extremity surgery

No studies looking at best prescribing practices in general surgery

J Urology. 2011. 185: 551-555J Oral Maxillofac Surg 71:1500-1503, 2013J Hand Surg Am. 2012;37A:645–650J Hand Surg Am. 2015;40(2):341e346

Bates C, Laciak R, Southwick A and Bishoff J.Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice J. Urol 2011; 185: 551.

275 patients Univ Utah responded phone or letter survey opioid consumption

90% given an opioid prescription

Mean number pills prescribed: 25

Only about half of prescribed opioids were consumed.

2/3 patients had opioids left over

Only 8% of patients were given instructions on how to dispose of leftover meds

Stopped short of recommending opioid prescription guidelines

Ann Surg 2017, 265: 709-14

Ann Surg 2017, 267: 468-72

J Am Col Surg, 2018, 226: 996-1003

Methods

• The 5 most common outpatient procedures performed June-Dec 2015:

partial mastectomy, partial mastectomy with sentinel lymph node biopsy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, open inguinal hernia repair

• Post-operative opioid prescription data and opioid refill data were obtained

• Patients with recent opioid use, history of opioid abuse, and those with post-operative complications were excluded

• We called patients and asked them how many opioids they took.

Partial Mastectomy

Partial Mastectomy with Sentinel Lymph Node

Laparoscopic Cholecystectomy

Laparoscopic Inguinal

Hernia Repair

Open Unilateral Inguinal Hernia

Repair

ALL CASES

Cases Performed

183 112 240 80 85 700

Number Patients

Excluded

8 8 32 4 6 58 (8%)

Chronic opioid use/

abuse

2 5 24 3 4 38 (5%)

Complications6 3 6 1 2 18 (3%)

Patients Analyzed

175 104 208 76 79 642

Cases Performed and Analyzed

PM (175) PM SLNB (104)

LC (208) LIH (76) IH (79)

Patients Receiving Opioid Prescription

129 (73.7%)

92 (88.5%)

205 (98.6%)

76 (100%)

79 (100%)

Opioid Pills Prescribed

Mean 19.8 23.7 35.2 33.8 33.2

Median 20 20 30 30 30

Range 0-50 0-60 0-100 15-70 15-120

Opioid Prescriptions

0

10

20

30

40

50

60

70

80

0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50

Perc

ent S

urve

yed

Popu

ltion

Pills Taken

B

Frequency of opioids prescribed (A) and taken (B) after partial mastectomy

N=175Median= 20Range= 0-50

0

5

10

15

20

25

30

0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50

Perc

ent T

otal

Pop

ulat

ion

Pills Prescribed

A

0

5

10

15

20

25

30

35

40

Perc

ent T

otal

Pop

ulat

oin

Pills Prescribed

0

5

10

15

20

25

30

35

Perc

ent S

urve

yed

Popu

latio

n

Pills Taken

Frequency of opioids prescribed (A) and taken (B) after laparoscopic cholecystectomy

A

B

N=208Median= 30

Range= 0-100

0

10

20

30

40

50

60

0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70

Perc

ent T

otal

Pop

ulat

ion

Pills Prescribed

0

10

20

30

40

50

0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70

Perc

ent S

urve

yed

Popu

latio

n

Pills Taken

N=76Median= 30

Range= 15-70

Frequency of opioids prescribed (A) and taken (B) after laparoscopic inguinal hernia repair

A

B

Home Opioid Use Summary:

Only ¼ of pills were taken!

Since our publication, several groups have described overprescribing:

1. Dartmouth orthopedics. Sabatino J Bone Jt Surg 2018; 100:1802. Mayo Clinic mult. ops, incl. nephrect, prost Thiels Ann Surg

2018; 268: 4573. Michigan, cholecystectomy. Howard JAMA Surg 2018 153:2854. UVM, several operations, including vasectomy and robotic

prostatectomy. Fujii M et al JACS 2018 226:1004

“Ideal” Number of Pills

PM PM SLNB

LC LIH IH

Ideal # pills 5 10 15 15 15

Calculated for each case by determining the number of pills that would fulfill the opioid use of > 80% of the patients

0

5

10

15

20

25

30

35

Perc

ent S

urve

yed

Popu

latio

n

Pills Taken

PM PM SLNB

LC LIH IH

Ideal # pills 5 10 15 15 15

Median # pills actually prescribed

20 20 30 30 30

57% decrease

84%

Effect of provider education intervention

We presented opioid use data and these guidelines at General Surgery section meeting, sent emails, resident teaching session April, May 2016

Recommended use acetaminophen and ibuprofen first, then opioids

• What % of pts will have 50% reduction in pain for 6 hours (Cochrane)?

Ibuprofen and acetaminophen: 73% ibuprofen alone: 52% Oxycodone: 23% placebo: 17%

Observed opioid prescribing patterns same 5 outpatient operations, June-September 2016, 224 patients

Collected data on opioid use

Comparison of opioid prescriptions pre vs post provider education

Mean number of opioid pills prescribed (SD)

Median number of opioid pills prescribed

Range

Operation Pre Post p-value Pre Post Pre Post

PM 19.8 5.1 0.0001 20 5 0-50 0-20

PM SLNB 23.7 9.6 0.0001 20 10 0-60 5-15

LC 35.2 19.4 0.0001 30 15 0-100 0-40

LIH 33.8 19.3 0.0001 30 15 15-70 0-30

IH 33.2 18.3 0.0003 30 15 15-120 0-40

Effect of education intervention on total number of opioid pills actually prescribed

53% decrease !

Were patient’s pain medication needs met?

Of 224 patients,

• Only 34% of the prescribed opioids were taken.

• Only 1 patient (<0.5%) required an opioid refill.

Answer: YES!

Analgesic use after partial mastectomy

0

10

20

30

40

50

60

70

80

90

100

Partial Mastectomy

% P

atie

nts

No OpioidAcetaminophen or NSAIDBoth Acetaminophen and NSAIDOpioid Only

How many opioids should be prescribed to patients who are discharged after surgery which

requires an inpatient admission?

Laws limiting number of pills prescribed to a “7 day supply”

Ambiguity: Is a 7 day supply 21 pills (1 every 6 hrs while awake) or 84 (2 every 4 hrs)?Do you assume the patients will use less pills every day?Is 7 days the right number, or 5, or 10?

Methods

Six common inpatient operations July –Dec, 2016:

Studied 333 patients

Excluded patients chronic opioid use, complications, discharged to nursing facility

85% sent home with opioid prescription

DC on POD =1 DC on POD ≥2

Home opioid use Inpatient use on day prior to discharge

Home opioid use

Analysis Groups

Home opioid use for patients discharged on POD 1

0

5

10

15

20

25

30

35

40

45Pe

rcen

t

Home Opioid Use After Discharge (Pills)

Univariate and multivariate analysis of factors associated with home opioid use

We found:

1) The number of pills taken the day prior to discharge was the best predictor of how many opioids were used at home

2) Opioid use at home after inpatient admission was independent of the operation performed

No opioid pills taken day prior to discharge

0

10

20

30

40

50

60

70

80

90

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Perc

ent

Home Opioid Use After Discharge (Pills)

1-3 opioid pills taken on day prior to discharge

0

5

10

15

20

25

30

35

40

0 1-5 6-10 11-15 16-20 21-25 26-30

Perc

ent

Home Opioid Use After Discharge (Pills)

≥ 4 opioid pills taken day prior to discharge

0

5

10

15

20

25

30

35

0 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 80-90 90-100

Perc

ent

Home Opioid Use After Discharge (Pills)

Prescription guidelines to satisfy 85% of patients’ home opioid usage

Discharge Date Number to Prescribe

POD =1

POD ≥2Pills used on day prior to DC

0 pills

1-3 pills

≥4 pills

15

0

15

30

Potential Savings in Opioid Pills Prescribed if our Guidelines were Used

40%

So, how many opioids should I prescribe to my next urology patient ?

1. You could use our guideline based on the number they used the day before discharge. (1 pill = 5 mg oxycodone)

Pills used day prior to discharge # Pills to prescribe

0 0

1-3 15

>4 30

Hill, Stucke, Billmeier, Kelly, Barth. JACS 2018; 226: 996-1003

So, how many opioids should I prescribe to my next urology patient ?

2. You could base it on operation specific consumption after discharge (Mayo guideline: http://links.lww.com?SLA/B477)

# of 5 mg oxycodone pillsN Median IQR (range) Guideline

MIS prostatectomy 105 4 0-15 15Robotic prostatectomy 17 4 (0-20) 15MIS nephrectomy 100 6 0-20 20Vasectomy 11 0 (0-2) 0Endoscopy 29 0 (0-10) 5

Mayo Guideline: 80% of the IQR for opioid naïve pts

Thiels C et al Ann Surg 2018; 268: 457-68Fujii M et al JACS 2018; 226: 1004-1012

“Hawkeye” Pierce, MDGeneral SurgeryAreas of Focus

• Trauma surgery • Hernia repair• Surgical critical care

Dr. Pierce had a great sense of humor but he didn’t give me enough pain medicine after my operation.

Potential Barrier to Surgeons Prescribing Less Opioids: Concern about Patient Satisfaction Scores

28.3

13.3

0

5

10

15

20

25

30

Period A Period B

P < 0.01

Mean Number of Pills Prescribed

Fewer Opioid Pills Prescribed

9.55 9.59

0123456789

10

Timeframe A Timeframe B

Overall Provider Satisfaction From All Patients (Index Plus Other cases) Throughout Study Period, N = 640

N = 236 404

P = 0.62 1 – 10 Scale

Highest

Lowest

What happens to excess pills?

FDA approved disposal:

• First DH outpatient study: 9%

• Our Inpatient study 1 year later: 19%

• Prospective study of pt info: 20%*

Take Back Days

*Hasak J et al JACS 2018 226: 235-40.

Next Steps…..excess pills problem

• Prospective study at Dartmouth to determine whether calling patients prior to their appointment after surgery increases use of an opioid drop-box in the pharmacy

• Will appropriate opioid prescribing and disposal decrease the % of patients using opioids one year after surgery?

• Applied for funding with U Michigan and others to prospectively study the use of a charcoal inactivation system (Deterra) to inactivate excess pills

Some good news……

• In 2017 the number of opioid pills prescribed nationally decreased by 9%.

• New Hampshire was the top state in the nation, with a 15.1% decrease in opioid prescriptions.